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DEPARTMENT OF SURGERY
68yr/M from Armala ,Ex Army by profession was admitted
through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief
• pain abdomen for 3 days
• Dyspepsia for 3 days
• Abdominal distention for 3 days
• Pain - in RIF
gradual on onset
started in the morning
no known aggravating factor
relieved by shifting position
Pain is associated with
H/O loss of appetite
• H/O passage of hard stool
• No H/O fever ,headache ,trauma
• No H/0 cough ,weight loss
• No H/0 vomiting.
• H/0 appendectomy 40 yrs ago
• From than ,he started to develop abdominal
pain of similar nature .
• According to him, he experiences similar
problem once in every year.
• Last time on Bhadra 2072 he was admitted to
GMCTH for abdominal pain ,admitted ,treated
conservatively and relieved.
• No such H/O in the family
• no H/O of HTN, DM, TB
• Consumes alcohol occasionally.
• Non vegeterian
• Doesn’t smoke
• But has a habit of chewing tobacco.
• No known allergic history of any drug
• GENERAL EXAMINATION
Pt .was concious, well oriented to T,P,P lying comfortably in supine
position with cannula fitted in the left hand
BP:- 110/70 mm of Hg in rt brachial Artery.
Temp 98 F
-umbilicus centrally placed and abdomen is
-visible scar in rt iliac fossa
-all quadrants move equally with respiration
-no visible pulsation and peristalsis
-hernial sites intact
-Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04)
-local temprature normal
-tenderness on lower abdominal region
-no palpable mass
-hernial sites intact and normal ext. genital
Percussion – resonant note
- tender RIF
-shifting dullness –ve
auscultation – normal bowel sound heard
-no vascular bruits heard
P/R exm- no mass, no blood, faeces present.
D/d For Against
Pain abdomen No antecedent
h/o of lower GI
Rt. Ureteric colic Abdominal Pain
No history of
no radiation to
D/D For Against
Severe pain in
pain is not
related to food
Crohns diseases Pain abdomen No diarrhoea and
Peristalsis is working against
a mechanical obstruction
Result from atony of the
intestine with loss of normal
peristalsis, in the absence of a
or it may be present in a non-
propulsive form (e.g. mesenteric
vascular occlusion or pseudo-
Small or Large bowel
High (Proximal) or Low (Distal) small bowel
According to LEVEL
High IO- near the ampulla- jejunum and
Low IO- distal to the ampulla- distal ileum
According to nature of Obstruction:
1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains
intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra-
abdominal adhesions, very rarely gallstones, ball of worms, bezoars).
2. Strangulation- the bowel lumen together with its blood supply is cut-off.
Eg. Strangulated inguinal hernias. Pure strangulation without bowel
luminal narrowing is usually due to mesenteric embolism/thrombosis.
3. Closed loop obstruction- The bowel is
obstructed both proximally and distally. Here
the blood supply may be impaired.
A classic example is seen in an obstruction of
the colon with a competent ileo-caecal valve.
NB: All the 3 types spoken about can occur at
the same time for example in a strangulated
According to onset:
-Chronic Obstruction-Usually seen in large
bowel obstruction. The symptoms may arise
from the cause and the subsequent obstruction.
-Acute on Chronic Obstruction- sudden
obstruction in a previously incomplete
Sub-acute Obstruction- There is a partial
The clinical presentation varies according to;
- The location of the obstruction
- The age of the obstruction
- Underlying pathology
- Presence or absence of intestinal ischaemia.
• Abdominal pain
• Feature of toxemia and septicemia
• Feature of strangulation
• Bowel sound
• Per rectal examination
• Electrolyte Na/K
• Plan X-ray abdomen erect and supine
• CT scan
(i) Supportive- FBC, BU+Cr. Other investigations may be
requested on the basis of clinical suspicion.
-Plain abdominal x-rays
Erect and supine
I.V fluids and electrolytes rescusitation
N.G tube if repeated vomiting
Volvulus derotate and or operate
Mesenteric ischemia operate
Abscess or peritonitis drain and treat
Intussusception pneumatic or barium reduction or operate
• SRB’s Manual of surgery, 4E
• Bailey & Love’s Short practice of surgery, 25th
• Principles of surgery